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Manual Therapy 10 (2005) 38–43

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Original article

Do Norwegian manual therapists provide management for patientswith acute low back pain in accordance with clinical guidelines?

Liv Inger Stranda,�, Alice Kvalea, Malfrid Raheima, Anne Elisabeth Ljunggrena

aDepartment of Public Health and Primary Health Care, Section for Physiotherapy Science, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway

Received 8 December 2003; received in revised form 4 May 2004; accepted 8 July 2004

Abstract

Manual therapists (MTs) are specialized in examining and treating patients with low back pain (LBP). The aim of the study was to

investigate if patients’ consultations with Norwegian MTs are in accordance with clinical guidelines for the management of acute

LBP. Semi-structured interviews were conducted based on observation of the first consultation. Twenty-two MT students observed

two consultations, and thereafter interviewed MTs (convenience sample) about clinical findings, information, advice and specific

therapeutic procedures given. The interviews were tape-recorded, transcribed, and organized. Forty-two reports were derived from

34MTs (12% of all in Norway). The MTs commonly informed the patients of main clinical findings. The intention to eliminate fear

avoidance was specifically mentioned in 43% of the interviews. Advice of being active in daily life activities was given to 50% of the

patients, and 43% were advised to avoid particular pain provoking movements. Working ability and sick leave was considered in

only 20% of those employed. The most frequent treatment modalities recommended were home-exercises (69%) and a combination

of joint mobilization and individually tailored exercises (48%). To some extent the MTs acted according to main points of clinical

guidelines. However, functioning at the participation level was little emphasized in the consultations.

r 2004 Elsevier Ltd. All rights reserved.

Keywords: Clinical guidelines; Acute low back pain; Manual therapists

1. Introduction

The prevention of long-term disability in back pain isa major challenge to health personnel. Fear avoidancebeliefs and catastrophizing related to the musculoskele-tal pain are claimed to play an important role in theprocess of developing disability (Waddell et al., 1993;Vlaeyen and Linton, 2000; Fritz et al., 2001; Buer andLinton, 2002). Carefully selected and presented informa-tion and advice to counteract negative thoughts andbeliefs, and educating and empowering patients to treattheir own problems, are recommended at an early stageof back pain management (Borkan and Cherkin, 1996;Waddell et al., 1997; Indahl et al., 1998; Burton et al.,1999; Hagen et al., 2000; Linton and Andersson, 2000).

see front matter r 2004 Elsevier Ltd. All rights reserved.

ath.2004.07.003

ing author. Tel.: +47-55586123, fax: +47-55586139.

ress: liv.strand@isf.uib.no (L.I. Strand).

Since 1993 clinical guidelines for the management ofacute low back pain (LBP) have been developed invarious countries based on systematic reviews ofpublished evidence (Burton and Waddell, 1998). Therehas been a progressive recognition that psychosocialfactors (yellow flags) are important determinants forrisk of chronicity and that such factors need to beaddressed clinically. Pincus et al. (2002) question,however, the emphasis on psychological factors incurrent guidelines, finding that they may go a littlebeyond the current evidence. According to guidelinesfrom 11 different countries, the identification ofpotential serious pathology (red flags) is a prime aimof the initial clinical assessment. Consistent features arealso the early and gradual activation of patients, anddiscouragement of prescribed bed rest (Koes et al.,2001). While manipulation is considered a potentialgood treatment within the first 4–6 weeks according to

ARTICLE IN PRESSL.I. Strand et al. / Manual Therapy 10 (2005) 38–43 39

some guidelines (United States, New Zealand, Finland,Switzerland, Sweden), the Dutch guidelines recommendthis treatment after 6 weeks within an active approach.Some question, however, the effectiveness of manipula-tion altogether (Israel, Australia).

Exercises are only recommended after 4–6 weeks inmost national guidelines (Koes et al., 2001), whilespecific exercises are not considered useful at all in theNew Zealand guidelines. The evidence summarized in asystematic review by van Tulder et al. (2000) indicatesthat specific exercises are not effective for the treatmentof acute LBP (o3 months), but might be helpful forpatients with chronic LBP to increase return to normaldaily activities and work. Maher et al. (1999) had asimilar conclusion from their systematic review. Acutepain was, however, in their study defined as pain thathad lasted for o6 weeks. They found strong evidencesupporting the use of structured exercise programs insub-acute (6–12 weeks) and chronic (43 months) non-specific LBP, and in the prevention of such problems.

Some studies have been conducted to examinewhether recommendations given in clinical guidelineshave been implemented into clinical practice (Schers etal., 2000; Gracey et al., 2002; Werner et al., 2002;Armstrong et al., 2003). Among treatment modalitiesgiven by physiotherapists in Northern Ireland topatients with LBP, advice was the most frequent, thenMcKenzie exercises and Maitland mobilization (Graceyet al., 2002). The nature and content of information andadvice was, however, not addressed. As questionnairesurveys of the therapists are most commonly used toexamine how back pain is managed, limited insight isgiven into what is actually communicated to the patientsduring consultations with health personnel.

Manual therapists (MTs) are physiotherapists specia-lized in examination and treatment of patients withmusculoskeletal conditions, particularly in primaryhealth care. They are presumed to be familiar withtopical results from clinical research and clinical guide-lines regarding treatment for patients with back pain.Patients with acute LBP are commonly referred fromgeneral practitioners to MTs for further examination,and eventual treatment. Some MTs in Norway, how-ever, may also be the primary contact for patients in theearly stage of back pain, and authorized to prescribesickness certification (o8 weeks). The aim of the presentstudy was to examine whether MTs acted in accordancewith clinical guidelines regarding information, adviceand other therapeutic procedures for patients withacute LBP.

2. Material and methods

Semi-structured interviews were conducted, afterstructured observation of how MTs acted in patient

consultations. The observations and interviews werecarried out by 22 MT students (physiotherapistsspecializing in manual therapy), 14 were men and 8women, mean age 37 years (SD 5), range 30–46 years.They were instructed during theoretical and practicalsessions in techniques of observation and interviewing.As the procedure is quite time-consuming, each MTstudent was to carry out data collection of only 2 patientconsultations with 1 or 2 MTs.

The students worked in supervised clinical practice indifferent parts of Norway. Accordingly, a conveniencesample of MTs from the Northern, Middle, South-Eastern and Western parts of the country were asked tobe informants (subjects) for the study. Written informedconsent was derived from the therapists, as well as fromthe patients. They were informed that the students wereto carry out a systematic study of clinical practice andreasoning in manual therapy.

2.1. Procedure

The students were to be present during the patientconsultation, but at a discrete distance, and should notinterfere. Each student had an instruction sheet contain-ing main points of what to observe (Table 1). They alsohad an instruction sheet of main themes to be pursued inthe following interview, regarding history, clinicalexaminations, information, advice and plan for treat-ment. The interviewer should try to repeat things saidand done by the MT during the patient consultation,and ask him/her to elaborate on the themes. Theinterview took place immediately after the consultation.It lasted for about an hour and was tape-recorded.

2.2. Analysis

The tape recordings were transcribed by the students,and analysed by the first author. Each interviewincluded extensive data from the consultation, particu-larly the history and the physical examination. However,only demographic data of the patient, and informationrestricted to the themes of the research question wasused in the present study, such as information given topatients, advice related to exercises, activities and work,plan for treatment, and adjacent clinical reasoning. Thenext step included organizing information from thereports in separate documents according to the themes.Main information was summarized using descriptivestatistics. Clinical reasoning of MTs was reported togive a fuller description of the material.

3. Results

A total of 42 reports were derived of patients withacute LBP based on consultations with 34 different MTs

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Table 1

Instruction sheet for observation

1. What does the MT ask the patient about?

2. Which examinations are done?

3. Which findings and information from the examination is communicated to the patient?

4. Which advice and points of view are imparted from the MT to the patient concerning movements, physical activity and work?

5. Which remedial actions does the MT suggest to the patient?

Table 2

Characteristics of demographic variables

Patients, n ¼ 42

Age, yrs: mean, SD, range 37, 12, 12–61

Pain duration, weeks: mean, SD, range 6, 4, 1–12

Gender, %: men, women 57, 53

Occupation, %: blue, white collar, no work 45, 42, 13

Sick leave of workers, %: yes, no 38, 62

Manual therapists, n ¼ 34

Age, yrs: mean, SD, range 43, 7, 33–58

Gender, %: men, women 71, 29

Clinical experience, yrs: mean, SD, range 10, 6, 2–26

L.I. Strand et al. / Manual Therapy 10 (2005) 38–4340

(12% of all MTs in Norway). LBP had lasted for o6weeks in half the group of patients. Demographicvariables of both patients and MTs are listed inTable 2. The clinical examination resulted in localizedpatho-anatomical explanation in approximately half ofthe cases. A bulging disc was suspected in 20% of thepatients, spondylolysis or spondylolythesis in 15%, and aneurogenic affliction in 11%. The most frequent func-tional aberrations reported were diagnoses not endorsedin the clinical guidelines, like spinal hypomobility (39%),and a combination of spinal hypo- and hypermobility(15%), and affliction of facet joints (13%).

3.1. Information of clinical findings

Most patients (90%) were informed of importantclinical findings during their first consultation. Theremaining MTs told some patients that they neededmore time or further examination to make a conclusion.Main findings from the examination were presented atthe end of the consultation. One patient, for instance,was informed that he had decreased mobility of thelower lumbar spine, another that he possibly had acentral disc protrusion, and a third that he hadasymmetry of the back muscles and decreased mobilityof the spine. When MTs sometimes explained in greatdetail to the patients during the course of examinationwhat they observed, they reasoned that this was done tomake the patients more educated and responsible fortheir treatment. Patients were commonly informed ofanatomical structures and function of the spine andtrunk. Different pedagogical aids were used such as

spine models, slide presentations and illustrations frombooks. Movements were demonstrated to let patientslearn about muscle function. The importance of suchinformation could be phrased as follows ‘‘the more thepatients understand, the better.’’

3.2. Fear avoidance

In 43% of the cases the MTs mentioned the intentionof decreasing fear and fear avoidance, specifically in theinterview. The importance of capturing the patients’thoughts and understanding of their painful conditionwas sometimes explored by asking open questions, suchas ‘‘what is it that concerns you about your back pain?’’Words like harm, damage and chronic were avoided,and the condition was intentionally characterized ascommon. As many patients were anxious about having aserious disease, positive information was consideredimportant to decrease fear. One patient, for instance,was reassured that he had no signs of serious pathology,another that she did not have sciatica or pelvic girdlerelaxation. It was stressed that defusing of symptomsand reassurance of the patient should be based onevidence from a thorough clinical examination. If aserious medical condition was suspected, the patient wasnot commonly informed at this first consultation, butwas referred for further examination (e.g. CT, X-rays).Sometimes the opposite of reassurance seemed appro-priate, as one MT said: ‘‘A reckless patient should bewarned about possible consequences of such behavior.’’

3.3. Advice related to daily activities

Advice about being active in daily life activities wasgiven to 50% of the patients. Such advice was mostcommonly given when patients were found to havespinal hypo-mobility and muscular tension. No patientwas advised to stay in bed. One MT clearly stated:‘‘Advice of being active rather than resting in bed is themost important information that can be given topatients with acute pain to avoid long-term disability’’.

A total of 43% of the patients were advised to avoidparticular pain provoking movements. Such movementswere typically lifting, bending and rotating the trunk,and sitting for a long time. Whenever registering painfulmovements, patients were shown alternative ways ofmoving. One patient, who complained of worsened

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symptoms while sitting, was shown an adjusted sittingposition, another who got pain during jogging, wasadvised to avoid that activity for a while. The otherpatients (57%) were not warned about particularmovements or activities. They were advised to bephysically active with activities that they liked. OneMT phrased it this way ‘‘by being active the patients willexperience that it is safe to move’’. Another MTmaintained that restrictions should not be given unlessthere were ‘‘red flags’’. When being afraid that painmeans harm, the patients might not only avoid the painprovoking activities, but limit physical activity ingeneral.

3.4. Advice related to work

Information about work status of 2 patients wasmissing. A total of 35 patients (88% of the remainingpatients) were employed, and 40% of the employed (14patients) were partly or on full sick leave. The MTsactively considered working ability and sick leave in20% of those who were employed, 5 were sick listed bythe MTs, while 2 were not. Patients tended to be onlypartly sick-listed by the MTs, and for a limited time (1–2weeks). They were advised to gradually increase workinghours as symptoms abated.

3.5. Exercise and manual techniques

A total of 69% of the patients were shown physicalexercises to be practiced at home. The treatment wasindividually tailored based on findings from the physicalexamination, often with the aim of improving mobilityand muscular control of the lumbar spine. Some patients(14%) were neither given home exercises nor generaladvice to be physically active. Approximately half of thepatients (48%) were to receive a combination of spinaljoint mobilization techniques and exercises, while onlymobilization techniques were given to 17%. Manipula-tion was prescribed for six patients (14%) found to havespinal locking, or hypo-mobility. Another six patients(14%) were to have exercises solely, and 20% receivedonly information and advice. Passive techniques likemassage and mobilization were sometimes suggested asfirst treatments, always to be followed by activeexercises. Spinal traction was never used. There wasno difference in treatment modalities suggested, com-paring groups of patients with LBP lasting foro6weeks, and between 6 weeks and 3 months.

4. Discussion

In this study, we have focused on information, adviceand other treatment given by MTs to patients with acuteLBP at first consultations, and adjacent clinical reason-

ing (Table 3). Recently developed clinical guidelines aremainly focusing on these aspects in treating LBP.Accordingly, we have summarized main findings withexisting clinical guidelines in mind. However, it isunderscored that a more qualitatively based analysis ofall aspects of our material would have given us theopportunity to describe and discuss a fuller picture ofthe consultations.

A large and varied group of MTs participated in thepresent study. However, as the MTs were not randomlyselected, we do not know whether the results reflect ifand how Norwegian MTs in general are using theclinical guidelines. The reader should further take intoconsideration that the results are based on the firstconsultation only. However, instructions about takingcare of the back tend to be given at the start of treatment(Kerssens et al., 1999). After the time of data collection,the Norwegian Multidisciplinary Clinical Guidelines forthe treatment of acute LBP were published (Nasjonaltryggnettverk—Formidlingsenheten, 2002). Whether thishas altered Norwegian MTs use of clinical guidelines, isnot known.

The study indicates that MTs usually inform andeducate patients, and thus empower them in theirrehabilitation process. To avoid unnecessary preoccupa-tion with bodily signs and symptoms, they tend toinform the patients of main findings only. In most cases(90%) the therapists were able to conclude with apossible cause or physical manifestations of the backpain, and were concerned about effectively informingthe patients. Such information is in accordance with UKClinical Guidelines for the Management of Acute LBP,stating that patients should be given accurate informa-tion about the structure and function of the back (RoyalCollege of General Practitioners, 1996 and 1999). Howmuch detailed information from the examination that ishelpful to the patient may, however, be questioned.

The importance of reducing fear and fear avoidancewas addressed by the MTs in relation to 43% of thepatients. In these cases the MTs sometimes asked open-ended questions to let patients express worries abouttheir condition. It is recommended that concerns andmaladaptive beliefs should be directly addressed at thefirst visit, as they may act as obstacles to recovery(Klaber Moffett, 2002). Misconceptions should bereplaced with an explanation that is credible, providingthe patient with confidence to encourage self-manage-ment. The patients were often reassured that therewere no signs of serious pathology, that back pain isvery common and that symptoms tend to abate oversome time.

Interestingly, the major group of MTs did not addressthe subject of fear avoidance. This may be due toignorance of the issue, or reflects the fact that not allpatients have fear related to their functional problems.In individual patients the reduction of fear avoidance

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Table 3

Main themes related to clinical guidelines addressed in MTs’ first

consultations with patients who had acute low back pain n ¼ 42

% of all cases (%)

Information of main clinical findings 90

Fear avoidance 43

Advice to avoid pain provoking movements 43

Advice to be active in daily life activities 50

Advice related to work 20

Home exercises 69

Exercises and joint mobilization 48

Mobilization techniques, only 17

Manipulation 14

L.I. Strand et al. / Manual Therapy 10 (2005) 38–4342

may be irrelevant, and even contra-indicated. Accordingto a recent systematic review by Pengel et al. (2003) thereis still limited evidence that fear avoidance is a clinicallyimportant prognostic factor of disability in acute LBP.

Advice to stay active in daily life is consideredimportant in the management of acute LBP for a fasterreturn to work, and for fewer chronic disabilities andrecurrence problems (Waddell et al., 1997; Bekkering etal., 2003). In the present study half the group of patientswere given such advice, consistent with the clinicalguidelines, but such advice might also be given later inthe course of treatment. Some MTs may, however,believe that physical exercise and manual therapytechniques are sufficient interventions to improve dailyfunctioning, and may for that reason simply notadvocate the resumption of physical activities.

The patients, who reported problems when perform-ing specific movements or activities due to aggravationof pain, were commonly helped to find alternative waysof moving. Such advice is partly in accordance withclinical guidelines. Recommendations are given in theUS Guidelines (Bigos et al., 1994) that specific activitieslike sitting for a long time, heavy lifting, twisting andbending are reduced or avoided in acute pain to decreaseexcessive loads on the back. In the New Zealand AcuteLow Back Pain Guide (ACC, the National HealthCommittee, 1997) it is acknowledged that activities andpostures may need to be modified in the short term.Patients are, however, recommended to increase physi-cal activity progressively according to a timetable ratherthan to be guided by the pain level. According toWaddell (1998), referring to the UK Clinical Guidelines,the patients should be recommended to continue normaldaily activities, and return to work as fast as possible.Depending on how bad the back feels, however,activities are suggested modified and medication recom-mended to control the pain.

There seem to be different opinions regarding adviceto modify or avoid painful movements. Vlaeyen andLinton (2000) argue that avoidance learning occurswhen the undesirable event has been successfullyavoided. Linton et al. (2002) attribute fear-avoidancebeliefs to health personnel who give advice that implyrestrictions of movements. MTs in our study, however,found patients less afraid of physical activities, afterthey had experienced control during graded or modifiedperformance.

Traditionally, physiotherapists in Norway need apatient referral from a physician. However, all MTs inNorway may, in the near future, become primarycontacts for patients with an acute episode of backpain, and given the authority to prescribe sick leave (o8weeks). At the time of the study, MTs of only threeNorwegian counties (two included in the present study)were trying out this new responsibility. When the MTsprescribed sick leave, they seemed to adhere to a time

contingent approach, consistent with evidence-basedguidelines (Bekkering et al., 2003). The relationshipbetween back problems and work were rarely addressedduring the first consultations.

The MTs often recommended exercise therapy in theactive phase of back pain, also when back pain hadlasted for less than 4 weeks. This is contrary torecommendations in most clinical guidelines of notrecommending exercises at all in the acute phase, only inlong-lasting back pain. Manipulation, which is recom-mended in some clinical guidelines, was only used in aminor group (14%) of the patients. The information andadvice, as well as specific therapeutic procedures givenby the MTs in the first consultations were commonlyindividually tailored. Reassurance and active copingstrategies seemed to be an important focus.

5. Conclusion

To some extent the Norwegian MTs did providemanagement for patients with acute LBP in accordancewith clinical guidelines, but little emphasis was placedon functioning on the level of participation, and the useof exercises was not in accordance with the guidelines.To answer the research question of the present study isnot straightforward. It should be emphasized thatguidelines are not prescriptive. Guidelines are based ongeneralized knowledge from controlled trials whereoutcomes of groups receiving different interventionsare compared statistically. In the clinic, as in our study,the individual patient stands out as the main focus, notthe group, and treatment is adjusted in accordance withthe individual patients’ problem. The importance ofsuch individually tailored treatment should, however, befurther explored in scientific studies.

Acknowledgement

The authors thank the manual therapists who will-ingly participated as informants in the study. The

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Masters students in manual therapy are thanked fordoing the elaborate work of collecting and transcribingthe data. Jostein Ellingsen, manual therapist and clinicallecturer, is thanked for being helpful in the planningprocess of the study.

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